Pharmacy Fee For Service Prior Authorization (PA) Contacts
Change Healthcare Pharmacy PA Unit
Toll-free: 877-537-0722
Fax: 877-537-0720
Registered Users in the Change Healthcare PA Portal
If you are a Mississippi Medicaid prescriber, submit your Fee For Service prior authorization requests through the Change Healthcare provider portal.
- Register or submit prior authorization requests through the Change Healthcare provider portal.
- MississippiCAN prior authorizations
Drug Prior Authorization Instructions (click here for instructions)
Please utilize the drop-down menus below to select the appropriate PA packet.
Prior Authorization Packets
| Prior Authorization Packets | Updated |
|---|---|
| Brand Name Multi-Source | 6/21/2019 |
| Early Refill | 6/21/2019 |
| Enteral Nutrition | 6/21/2019 |
| EPSDT – Beneficiaries Under 21 | 6/28/2019 |
| Growth Hormone | 10/1/2021 |
| Hepatitis C Therapy | 6/1/2021 |
| Max Unit Override | 6/21/2019 |
| Multiple Concurrent Antipsychotics for Beneficiaries (Age < 18) | 6/21/2019 |
| Opioid Packet – Effective 8/1/2019 FAQs | 9/10/2019 |
| PDL Exception Request | 6/21/2019 |
| RSV-SYNAGIS®
DOM will begin accepting Synagis prior authorization requests on October 11, 2021 for DOS beginning November 1, 2021 |
9/30/2021 |
| Universal Prior Authorization Form | 6/21/2019 |
Manual PA Criteria
| Manual Prior Authorization Criteria | Updated |
|---|---|
| Akynzeo | 2/3/2020 |
| Antipsychotics | 2/3/2020 |
| Austedo | 6/10/2020 |
| CGRPs | 5/26/2021 |
| Corlanor | 2/3/2020 |
| Cresemba | 2/3/2020 |
| Dupixent – Asthma | 2/3/2020 |
| Dupixent – Atopic Dermatitis | 2/3/2020 |
| Dupixent – Nasal Polyposis | 12/27/2021 |
| Emflaza | 2/3/2020 |
| Endari | 2/3/2020 |
| Eucrisa | 4/1/2020 |
| Evrysdi | 4/6/2021 |
| Exondys | 2/3/2020 |
| Farydak | 2/3/2020 |
| Hemlibra | 2/3/2020 |
| Ingrezza | 2/3/2020 |
| Jadenu | 2/3/2020 |
| Juxtapid | 2/3/2020 |
| Kalydeco | 1/27/2021 |
| Lotronex | 2/3/2020 |
| Lynparza | 6/3/2020 |
| Mavenclad | 2/3/2020 |
| Mayzent | 2/3/2020 |
| Ocrevus | 2/3/2020 |
| Orkambi | 2/3/2020 |
| Oxbryta | 2/28/2020 |
| Palforzia | 12/16/2020 |
| Praluent | 10/27/2019 |
| Probuphine | 2/3/2020 |
| Repatha | 10/16/2019 |
| Sivexto | 2/3/2020 |
| Stribild | 2/3/2020 |
| Sublocade | 2/3/2020 |
| Symdeko | 1/27/2021 |
| Trikafta | 7/9/2021 |
| Tybost | 2/3/2020 |
| Varubi | 2/3/2020 |
| Viltepso | 1/21/2021 |
| Vivitrol | 2/3/2020 |
| Vyepti | 2/10/2021 |
| Vyondys 53 | 1/22/2021 |
| Zontivity | 2/3/2020 |
| Zyvox | 2/3/2020 |
Physician Administered Drug (PAD) Prior Authorization Instructions
Alliant Health Solutions is the current vendor for physician administered drugs. Please click here to direct you to the Alliant official website. As a reminder, please submit physician administered drug PA requests through Alliant.
Physician Administered Drug - PA Criteria*
- Exondys Initial
- Exondys Reauthorization
- Kymriah
- Luxturna
- Spinraza Initial
- Spinraza Reauthorization
- Vyondys
- Yescarta
- Zolgensma
* PA criteria is maintained by Alliant Health Solutions.
